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Thursday, 31 March 2016

Back in the 1960s, when the Pill became available in Aotearoa New
Zealand, the New Zealand Branch of the British Medical Association (the precursor
to today’s NZMA) decided it would be unethical for doctors to let unmarried
women get their hands on it. Doing so, it was argued, would be akin to doctors giving
extra-marital relationships a stamp of approval, and the NZMA wasn’t about to
do that.

If you thought doctors keeping us from
the Pill for our own good was a thing of the past, think again. Sure, it’s no
longer under the guise of protecting our moral purity – (most) doctors have
(mostly) given up on that argument. Now, it’s all about protecting our health.

As recently as 1996, both the Royal
College of General Practitioners and the NZMA opposed the reclassification of
the Emergency Contraceptive Pill so it could be purchased in pharmacies. “We have concerns that in a pharmacy the patient may be disadvantaged
from receiving the greater advice that would occur in a general practice
consultation,” the college’s chairman, Professor Gregor Coster, was quoted as
saying in an article in the British Medical Journal.

Fast forward to 2016, and a new front in
this seemingly endless struggle is focused on efforts to get the Pill, aka oral
contraception, liberated from doctors’ prescription pads and made available
over the counter. The most recent round began in 2014, when Pharmacybrands Ltd
(now Green Cross Health, which represents 300 community pharmacies and has an equity interest in 80) and
Pharma Projects Ltd, (now Natalie Gauld Ltd.) made an application to Medsafe’s
Medicines Classifications Committee to reclassify the Pill so it could be sold in
pharmacies without prescription, though only by specially trained pharmacists,
following the model that’s now used for the Emergency Contraceptive Pill.

That
application was turned down in the face of stiff opposition from general practitioners and the NZMA: the latter
said they didn’t think prescription only access was a barrier to the Pill and wanted
to make sure doctors continued to provide “the advice and counselling about its
use and about sexual health in general”, while the College of GPs, apparently
felt “as if they are being excluded from an important
part of primary health care”. (Never mind that the actual users of this
“important part of primary health care” were – and continue to be – excluded.)

On the plus side, the New
Zealand Committee of the Royal Australian and New Zealand College of Obstetricians
and Gynaecologists (is that a long enough title for you?) backed the
reclassification saying it was “strongly in support of any responsible
development designed to improve access to quality contraceptive advice and
service”.

Not to be discouraged
by the initial setback at Medsafe, the applicants tried again early in 2015,
and were – again – rejected. This time, however, they lodged an objection to the decision and at the same time
proposed an alternative to the Emergency Contraceptive Pill model, whereby only
women who have previously had oral contraceptives prescribed by a doctor could
access the medication without a script at a pharmacy.

It was all looking
pretty rosy when the committee went along with the “previous prescription”
model and said yes. But wait, not so fast. Perhaps still feeling “excluded”, the
Royal New Zealand College of GPs lodged their own objection earlier this year, arguing that there had been no public consultation on Green Cross’s
“been previously prescribed the pill” idea. The College put out a media release explaining what they’d done, and re-stating
their firm opposition to any loosening of doctor control over oral
contraceptives: “Our members strongly opposed the original application to
reclassify the oral contraceptive pill on the grounds that while it is a safe
and effective contraceptive for the majority of women, for some women it is
not, and alternative contraception methods need to be prescribed.”

It’s worth noting at
this point that GPs are actually pretty well represented on Medsafe’s Classifications
Committee, which leads inquiring minds to wonder whether or not they might have
a conflict of interest when it comes to the prospect of losing repeat
Pill-prescribing business. According to minutes from the April 2014 and May 2015
meetings, however, none of the Committee members, reported themselves for
having any such conflicts.

And of course, on the
applicant side of the equation, having more medicines available from pharmacies
is certainly better for their bottom line as well. Indeed, there’s a bit of a turf
war going on between doctors and pharmacists as a recent New Zealand Doctor article made clear. Titled “General practice get
ready – pharmacy is on the rise”, the article points out that that the
government is more than eager to see pharmacists take on more of the work GPs
have traditionally done. Though the article doesn’t say so, it’s hard to avoid
the conclusion that this, too, has something to do with the bottom line.

HOW
IT MIGHT WORK

Dr. Natalie Gauld, one
of the applicants seeking reclassification, is a pharmacist and sat on the
Medsafe Classifications Committee from 2004 to 2009. She told me there
were a few medicines she thought could be available without a prescription,
including oral contraception, and when she left the committee, she started working
with Green Cross on trying to get them reclassified.

While she doesn’t want to talk
about Medsafe’s decision-making while it’s still going on, she did explain how
accessing the Pill over-the-counter might work for New Zealand women. “Amodel
increasingly used in New Zealand is pharmacists being specially trained, and
using a questionnaire – a screening tool. What it means is that it’s not a
two-minute ‘go and ask for something and leave’, but it would be a careful consultation.
So even if somebody has got it from the doctor in the last three years, there’s
still going to be a health professional responsibility to ensure that the woman
fits the criteria that allows the pharmacist to supply it.

“So for the combined oral contraceptive,
it would be things like a blood pressure check once a year, and … checking for
things like migraines, and age and other risk factors to ensure that women at a
higher risk of side effects that are important won’t be supplied through the
pharmacist.”

HOW MUCH MIGHT IT COST?

Cost decisions are separate from
decisions about reclassifying a medicine – Pharmac and DHBs usually sort out
the funding, while Medsafe sorts out where and how medicines can be sold. In
some areas, for example, the Emergency Contraceptive Pill is funded for young
women when they get it without a prescription from the pharmacy, but not in all
areas. So the DHBs sometimes choose to fund drugs through pharmacies
differently in different areas.

If there isn’t any funding for
the Pill at the pharmacy, which is the most likely outcome, the cost could be
around $45 for a three-month supply. However, women could still access the Pill
through their doctor or Family Planning clinic, in which case the status quo
would apply: the cost of the consultation (free for under-22s at Family
Planning) plus the standard prescription fee of $5.

IS IT SAFE?

So what about these arguments GPs
and the NZMA like to make that letting women decide for themselves whether or
not to take the Pill is just too dangerous? There are rafts of studies looking
at the risks and benefits of widening access to the Pill – and two great places
to read about some of them are at the U.S.-based “OCsOTC” (Oral Contraceptives Over-The-Counter) and “Free the Pill”.

As Free the Pill points out, the
risk of misuse or abuse is low “you can’t overdose on the pill”; the directions
are simple “you just take one every day”; women are smart enough to use
checklists to assess their own risks; not to mention that the Pill has health
benefits in addition to the big one of preventing unplanned pregnancy: “It
reduces pain and heavy bleeding with periods, helps prevent acne and anaemia,
reduces the risk of certain cancers, and more. A study in the medical journal The Lancet showed that over the last 50
years the pill has prevented 200,000 cases of ovarian cancer and 100,000 deaths
from the disease.”

Lots of other countries allow it,
particularly in the Global South, with moves to expand access in the U.S. and
U.K. (For an interactive version of the map below, click here.)

'Global Oral Contraception Availability. From the OCs OTC (Oral Contraceptives Over the Counter) Working Group

In January of this year, a law allowing over the counter sales – though only
through specially trained pharmacists and only for women aged 18 or over – came
into effect in the U.S. state of Oregon, with California about to follow suit
and Colorado, Washington and New Mexico thinking about it.

Oregon and California have faced
the usual critics, plus some on the other side of the issue, who argue their
laws don’t go far enough to improve access to contraception. Here at home, as
ALRANZ pointed out in a perhaps prematurely positive media release, the
“previously prescribed” model is only a start. We need better access – which
includes affordability – to all forms of contraception, not just the Pill.

In the end, it’s hard to see how
making this medication hard to get isn’t rooted in good old paternalism and
moralism whereby doctors, churches and governments want to keep control over female
sexuality. That, mixed with a little bit of self interest. Sometimes, it feels
like the 1960s aren’t that long ago after all.

2 comments:

Thanks so much for such good information on this, Alison. As it happens I had just copied those NZMA ethics committee quotes - in 1961 they didn't want ANYONE to get the pill unless there was a danger to the woman's health or life. But to be fair, most doctors ignored them on that one, though getting it if you were single was much more problematic. Even at Family Planning in 1965, I had to give them my fiance's name and address and the date of the wedding.

Thanks Anne. Amazing, eh. I was unable to find the 'original' quote from the NZMA (equivalent), actually, instead quoting from Helen Smyth's excellent 'Rocking the Cradle.' Am thinking of doing a bit more work on this topic, so perhaps I could hit you up for the original...?